心內(nèi)超聲和心電生理英課件

1、 intracardiac echocardiography and electrophysiologydisclosures biosense webster- consultant, investigator acuson/siemens- consultantcurrent clinical applications for intracardiac echocardiography (ice)electrophysiology transseptal puncture vt ablation aortic cusp and rvot ablation lv ablations comp

2、lex left-sided procedures atrial flutter ablation placement and removal of pacing leads bi-ventricular pacing for cardiac resynchronizationice imaging - transseptal左邊影象證明了房間隔穿刺后的tenting現(xiàn)象，請(qǐng)注意tenting在肺靜脈平面是最大的，以利于在肺靜脈、肺靜脈前庭以及左房后壁的控制。右圖證明了正確的房間隔穿刺。using ice to guide transseptal puncture在ice的幫助下，可以避免不恰

3、當(dāng)?shù)姆块g隔穿刺左側(cè)影像表明穿刺針/鞘位置靠前，幾乎從左房前部穿出右側(cè)影像表明在嘗試穿房間隔時(shí)穿刺針從右房穿入主動(dòng)脈根部aortic cusp vt ablation這些圖象演示了在標(biāo)測(cè)一個(gè)局部vt消融時(shí)，從動(dòng)脈瓣膜看動(dòng)脈根部的影像。利用多普勒影像能通過(guò)直接的可視化圖形確認(rèn)冠狀動(dòng)脈開口。這可以幫助指導(dǎo)在這個(gè)區(qū)域的安全的消融。lv ablation這些圖片顯示的是合并巨大基底動(dòng)脈瘤的左室影像。注意導(dǎo)管的位置在動(dòng)脈瘤邊緣。右上圖顯示在射頻消融因局部過(guò)熱產(chǎn)生的微泡use of intracardiac echo (ice) imaging for la ablationtransseptal punc

4、turepre ablation anatomical orientationconfirmation of catheter positioningassessment of lesion formationdetection of complicationsabnormal la anatomy這是一個(gè)復(fù)雜的解剖案例。ct圖演示了在左上及左下肺靜脈分叉之前的共干及巨大的左大前庭開口。左圖證明左肺靜脈共干前庭開口為2.9cm。這個(gè)ct圖演示了三個(gè)左肺靜脈。ice可以形象化的演示異常左肺靜脈，減少了肺靜脈消融的危險(xiǎn)性。這是一個(gè)很罕見的左房，常見的低位開口。ice證實(shí)后位開口（上圖）及巨大的左上

5、肺靜脈（下圖）。 ice能直接的顯示這類復(fù)雜解剖病例的病變部位畸形左房。左肺靜脈共前庭，右上肺靜脈靠前，右下肺靜脈靠后，左房頂部正中有一單獨(dú)肺靜脈。3d ct圖象掃描和ice能對(duì)這種復(fù)雜的解剖結(jié)構(gòu)的標(biāo)測(cè)和消融有幫助。identify anatomyuse color doppler and spectral doppler to evaluate laaice能在直視或多普勒超聲影像下區(qū)分左心耳及左上肺靜脈這可以減少不適當(dāng)?shù)淖笮亩僮?，從而減少左心耳穿孔的風(fēng)險(xiǎn)left pulmonary veins左圖演示了lasso進(jìn)入了一個(gè)共干的左肺靜脈口的左下分支，右圖是正常的lasso放置位置，正確的

6、放置能改善隔離、消融gap。color doppler with cryocath balloonice能幫助定位array導(dǎo)管的大小及位置。多普勒超聲能進(jìn)一步證實(shí)位置的準(zhǔn)確性esophagusinsert barium swallowice放置右房能顯示食道，通過(guò)上圖能顯示左右肺靜脈和消融導(dǎo)管。right pulmonary veins右側(cè)肺靜脈的橫切面（左圖）及縱切面（右圖）可通過(guò)房間隔后斜進(jìn)入而顯示該患者有三支右肺靜脈，有一束組織從右上及右中肺靜脈之間的突起處延伸至后壁直接顯示肺靜脈及該束組織能指導(dǎo)lasso及消融導(dǎo)管在該部位的操作intra-procedural early detec

7、tion of complications在左房手術(shù)中，我們抗凝較積極，維持inr在2-3， acts 350s以防止在標(biāo)測(cè)及消融導(dǎo)管上的血栓形成。低于該標(biāo)準(zhǔn)的抗凝則需要房間隔穿刺以及心內(nèi)導(dǎo)管的操作很精確。如果血栓形成則在ice能看見并能回縮至鞘內(nèi)或者直接拉回右房scattered “micro-bubbles”brisk shower of dense “micro-bubbles”ice顯示非灌注射頻消融技術(shù)的損傷，過(guò)熱能導(dǎo)致pop現(xiàn)象的產(chǎn)生，識(shí)別微pop現(xiàn)象能減少能量輸出和防治大pop現(xiàn)象。intra-procedural detection of potential complicat

8、ions 過(guò)熱能導(dǎo)致過(guò)度的心內(nèi)膜損傷（左圖），導(dǎo)致內(nèi)膜下基質(zhì)暴露，從而形成血栓在左房和心室消融中，過(guò)熱能產(chǎn)生結(jié)痂形成和導(dǎo)致中風(fēng)的潛在原因，在適當(dāng)?shù)哪芰亢屠湎趯?dǎo)管能防止結(jié)痂（左圖顯示在lasso上和右圖顯示大頭）012345678stroke/tia% patientsultrasound 33 ptstemperature control482 ptsice + bubbles 270 ptsp = 0.029p = 0.2embolic complications過(guò)去的一項(xiàng)研究表明通過(guò)ice監(jiān)測(cè)微泡的形成以防止過(guò)熱能顯著減少在復(fù)雜左房消融中腦卒中的風(fēng)險(xiǎn)monitor for pericar

9、dial effusioncardiac tamponade在這個(gè)圖片中ice導(dǎo)管能早期監(jiān)控和診斷心包滲出。evaluate pulmonary venous flowleft inferior and superior pulmonary veins功能顯像能證實(shí)在左房消融前后通過(guò)肺靜脈血流是否正常results - severe pv stenosis0510152025cartodistalisolationproximalangioiceice withbubblescircular mappingcarton=75 n=25 n=102 n=100 n=310 20.0%2.9%2.

10、0%0%15.5%通過(guò)確認(rèn)適當(dāng)?shù)姆戊o脈前庭損傷，而不是深部肺靜脈的損傷，ice已經(jīng)被顯示防止肺靜脈狹窄。visually assists with anatomical map unusual anatomical variants vertical or horizontal hearts congenital anomalies any post-operative heart common left ostium rapid branching of either vessel multiple branches of right veinscarto and ultrasound與精確

11、標(biāo)測(cè)系統(tǒng)的三維圖像融合能直觀地顯示復(fù)雜解剖結(jié)構(gòu)在ct殼下顯示導(dǎo)管位置能準(zhǔn)確地顯示病變位置及導(dǎo)管穩(wěn)定性，從而減少放射線暴露lupvice能幫助ct圖象重構(gòu)選擇位點(diǎn)。landmark registration在復(fù)雜的左房消融時(shí)，我們通常在左房?jī)?nèi)標(biāo)記三點(diǎn)（左上肺靜脈的后上，左下肺靜脈后下及右上肺靜脈的后上）left atrium and pulmonary veinscartomerge形象化的提供在復(fù)雜解剖結(jié)構(gòu)中動(dòng)態(tài)的多種工具。cartosoundoverview of the cartosound image integration module and the soundstar 3d cat

12、hetercartosound module featuresaccuracybeam orientationcartosound module mapstip to tissue contact visualizationcartomerge module synergycartosoundbeam orientation displaying the real-time ultrasound beam in 3d space improves ease of use and allows for easier interpretation of icecartosoundbeam orie

13、ntationdisplaying the real-time ultrasound beam in 3d space improves ease of use and allows for easier interpretation of icecartosound cartosound module maps allows for faster and more accurate maps safely create left sided maps from the right sidecartosound tip to tissue contact improves physician

14、confidence with real-time tip to tissue visualization在實(shí)時(shí)的ice圖象和重建的3d ice圖象能顯示導(dǎo)管位置在上圖中。cartosoundcartomerge module synergy first ice & 3d mapping integration enhancing safety & ease of use two years of proven accuracy & experience full anatomical details of pre- acquired registration綜和ice和3d系統(tǒng)能實(shí)時(shí)顯示大頭、解剖、3d重建圖和三維標(biāo)測(cè)系統(tǒng)。conclusions ice provides real-time 2d and functional imaging to help guide catheter manipulation in difficult anatomy, monitor lesion formation, pr